A Collision of Ideas: Synthesis or Destruction?

The comments shared yesterday from a well-respected Dean of a medical school highlight a collision of ideas. On the one hand, we have Complexity Theory attempting to "make sense" out of the complex problems in health care. On the other hand, we have another powerful force, "disruptive innovation", that maximizes value out of simplification of complicated and complex problems. Are these two apparently competing philosophies on a collision course? Will they demolish each other and leave us picking up the pieces? Perhaps, unless we can BE SMART.

I hope all of you had a chance to reflect upon the questions yesterday. The comments have been extremely well-thought and insightful. The Dean has outlined truly complex health care problems that need complex answers. I think "value" is somewhere in those answers. Long-term value, not short-term.

What do I mean by that? Well, let's look at another powerful philosophy: disruptive innovation. This is the keen observation by Clayton Christensen and colleagues http://www.claytonchristensen.com that technological innovation coupled with a simpler, cheaper, more convenient or quicker will allow a newcomer in an industry to effectively compete at the low end of a market, and move "upscale", taking more and more profits from the incumbents. To start with, their product is not better, but it is "good enough". Disruptive innovation is possible in an industry in which the current products are actually better than that required by the consumers. They are not willing to pay more for any further improvements, but will change their purchasing habits for something cheaper, quicker, more convenient or more simple. Think of how Sony disrupted the radio market 50 years ago. Can you find an RCA radio anymore? Or the Honda 50 and the motorcycle market, with subsequent jump to the auto industry.

In "The Innovator's Prescription" http://innovatorsprescription.com/Christensen and coauthors Jason Hwang and the late Jerome Grossman apply a similar philosophy to health care. Illustrative is the case of the "Minute Clinics"--those small clinics that are set up in grocery stores or pharmacies, treat limited disease such as sore throat or tetanus shot, involve little wait and, at least at their inception, avoided the whole insurance and delayed-payment morass. They are extremely effective, and profitable. They also ONLY treat "simple" (not even "complicated") problems.

The authors also recommend that technological advances such as molecular and imaging diagnostics, can avoid "expensive, highly-skilled experts" and simplify the diagnostic process. Treatment can then be relegated to specialized "process" treatment centers that apply rule-based care. Facilitated patient networks will care for complex chronic diseases. The approach is based upon reductionism and highly emphasizes process. Structure and starting point are not mentioned. While I have no doubt that this works with most simple and even some complicated problems, I believe it will prove to be ineffective for complex problems. What works in treating diabetes in Boise may not work in Boston. Or on the Navajo Reservation. Or in the Inner City of Detroit. Or in rural Mississippi.

The authors also believe that "simple" Primary Care (an oxymoron in my estimation) can be relegated for the most part to non-physician extenders. Primary Care may be able to be done, and done best in some situations, by some non-physicians, but not because Primary Care is simple! The truth of the matter is that there are some simple problems and some complicated problems in health care, but the differentiation of what is simple, complicated and complex is COMPLEX. This is one of the dilemmas we must solve. A "wicked problem" indeed.

For such problems, David Snowden's Cynefin Framework recommends Probe-Sense-Respond. In my estimation, this is what should be done. I don't know the answers to these questions, and I don't know the answers to the Dean's questions. The answers will be EMERGENT, because they are complex! But I think Complexity Theory and the Cynefin Framework tells us how best to find the answers.